OB billing glossary

The span of care a single procedure code covers. For the global OB package it runs from the first antepartum visit through routine postpartum care, so services inside that window are not separately billable unless an exception applies.

The unit Medicare uses to weight physician work, practice expense, and malpractice cost for each code. Multiply total RVUs by the annual conversion factor (and locality adjustment) to get the Medicare payment.

CMS's National Correct Coding Initiative pairs of codes that cannot be billed together on the same day. When a claim hits an edit, the lesser service denies, usually as CO-97, unless a modifier documents a distinct service.

The interpretation-and-report half of an imaging or diagnostic service. Billed with modifier 26 when the interpreting physician does not own the equipment.

The equipment, supplies, and technologist half of an imaging or diagnostic service. Billed with modifier TC by the entity that owns the equipment.

Pregnancy care before delivery. Inside the global package this means the routine visit schedule, roughly 13 visits for a term pregnancy. Antepartum-only codes 59425 and 59426 apply when care transfers before delivery.

When a patient changes practices mid-pregnancy. The practice that does not perform the delivery forfeits the global fee and bills antepartum-only codes based on visit count.

The two-digit claim field identifying where the patient received care. For telehealth, POS 10 means the patient was at home; POS 02 covers other originating sites.

Billing a non-physician provider's service under a supervising physician's NPI at 100% of the fee schedule, subject to strict supervision and established-plan-of-care rules.

The regional contractor that processes Medicare claims and publishes local coverage policies. Fee schedule amounts and some coverage rules vary by MAC locality.

The single-code bundle covering routine antepartum visits, the delivery, and routine postpartum care, billed once at delivery (59400 for vaginal, 59510 for cesarean). Ultrasounds, NSTs, and problem visits with their own diagnoses fall outside it and bill separately.

The two NCCI edit families. Procedure-to-procedure (PTP) edits block code pairs billed together on the same day unless a modifier documents a distinct service; medically unlikely edits (MUE) cap how many units of one code a single patient can plausibly receive per day.

A two-character suffix that changes how a payer reads a code without changing the code: which component was performed (26, TC), that a service was distinct from another billed the same day (59, 25), or that the work was substantially greater than typical (22).

The two code sets on a remittance. Claim adjustment reason codes (CARCs, like CO-97 or CO-50) state why payment was adjusted or denied; remittance advice remark codes (RARCs, like N290 or MA130) add the specifics, such as which field was missing. Read them as a pair.

Payer approval obtained before a service is delivered, without which the claim denies regardless of medical necessity. In OB it most often attaches to detailed ultrasounds, genetic testing, and home monitoring, with lists that vary by plan and change yearly.

The payment model for federally qualified health centers: one bundled rate per qualifying face-to-face encounter instead of fees per service. It is why the global OB package does not apply in FQHCs; each prenatal visit bills as its own encounter.

Temporary Medicaid coverage a qualified provider can grant a pregnant patient on the spot, based on stated income, so prenatal care starts before the full application is decided. It covers ambulatory prenatal care but generally not the delivery.

A claim with every required element present and valid, processable without requests for more information. Clean-claim status starts the payer's prompt-payment clock; defects surface as CO-16 rejections that pause payment without pausing timely filing.

The payer's deadline for receiving a claim after the date of service, commonly 90 days to a year and often shorter under managed-care contracts. Rejected or unprocessable claims usually do not stop the clock, which is why claim defects need same-week fixes.

A second, formal interpretation of an imaging study by a specialist, typically an MFM physician reviewing an ultrasound performed elsewhere. Billed as the professional component (modifier 26) by the interpreting physician when the payer's re-read rules are met.